Environmental Design for Patient Families in Intensive Care Units

The purpose of this paper is to define the role of environmental design in improving family integration with patient care in Intensive Care Units (ICUs). It argues that it is necessary to understand family needs, experience and behavioral responses in ICUs to develop effective models for family integration. With its two components—the “healing culture” promoting effective relationships between caregivers and care seekers, and the “environmental design” supporting the healing culture—a “healing environment of care” can be an effective family integration model. This paper presents evidence showing how environmental design may affect families in ICUs, and proposes design recommendations for creating a healing environment of care promoting family integration in ICUs.


INTRODUCTION: WHY FAMILY INTEGRATION WITH PATIENT CARE IS IMPORTANT IN ICUS
The Society of Critical Care Medicine (SCCM) and the American College of Critical Care (ACCC) have adopted the definition of "family" provided in the Palliative Care Guidelines: "Family is defined by the patient or in the case of minors or those without decision making capacity by their surrogates.In this context, the family may be related or unrelated to the patient.They are individuals who provide support and with whom the patient has a significant relationship" [1].Since critically ill patients are often unable to communicate and make decisions, families can make important contributions to care decisions on behalf of these patients [2][3].Families can also help busy ICU nurses and physicians become more effective and efficient [4][5].Simpson [6] studied various supportive functions of families in ICUs.Simpson's findings, as represented in Figure 1, fall well within the natural role of a family, as defined by Caplan [7].
To recognize the importance of families in patient care, the concept of familycentered care was developed [8].Importance of the family was also recognized in the patient-centered model of care [9].The key elements of these models are quite similar: a) keep patients and families informed and actively involved in medical decisionmaking and self-management; b) coordinate and integrate patient care across groups of healthcare providers; c) provide the physical comfort and emotional support for patients and family members; d) understand patients' concepts of illness and their cultural beliefs; and e) understand and apply principles of disease prevention and behavioral change appropriate for diverse populations.
Several studies have demonstrated that patient-/family-centered care is associated with better clinical outcomes [10][11][12][13].At the same time, patients and families are expressing a desire for a larger role in healthcare decision-making and are asking providers to do a better job of responding to patient and family needs [14][15][16].Despite these concerns, families and other surrogates often feel uninformed, and disenfranchised from clinical decision-making and day-to-day care of loved ones in the ICU [17][18].To Foster a link between patients and the environment

Supportive functions of families in ICUs
Assist patients to process concerns about health cognitively

Assist patients with daily functions that patients cannot perform
Help enhance positive relationships by offering love and comfort Help reinforce positive selfesteem

Figure 1.
The supportive functions of families in ICUs based on Simpson [6].
achieve a culture of patient/family centered care aimed at integrating families with patient care, an environment to support the care model must be considered.This paper introduces the concept of a healing environment of care as a model for family integration in ICUs, and argues that most existing models of care focus primarily on the cultural dimensions of healing and disregard the role of environmental design (ED) dimensions in promoting family integration.It presents related research evidence on the effects of ED on family needs and experience, and makes ED suggestions aimed at promoting family integration with patient care in ICUs.It also discusses barriers to implementing healing design in ICUs.environmental effects on healthy individuals in office settings may be somewhat similar to that on patient family members in healthcare settings.
Limitations to the methodology pertain primarily to ED findings and recommendations concerning patient families.Very few studies have reported effects of ED on families in ICUs.Even fewer studies have reported studies that focus on design interventions in ICUs aimed at improving family outcomes.Altogether, only 10 out of all the cited articles in this paper are directly relevant to ED for patient families in ICUs [19][20][21][22][23][24][25][26][27][28].
In an important study to determine the perceived needs of families of critically ill patients, Molter [5] developed a list of 45 need statements to be rated on a scale of 1 to 4. In the study, Molter found that many of the most important needs identified corresponded well to the comfort measures identified in other studies.Further, none of the 10 most important needs identified by her subjects was influenced by age and socioeconomic status, indicating that these needs are very important to most family members and, therefore, should be a major concern to caregivers.Molter and Leske [36] revised Molter's initial list to create the Critical Care Family Needs Inventory (CCFNI) for family assessment and self-report of specific needs.Daley [32], Norris and Grove [30], Rodgers [32], and others replicated Molter's work in other critical care settings with comparable findings.Leske [37] studied the psychometric properties of the tool, and identified five categories of needs: assurance, proximity, information, comfort, and support needs (Figure 2).Other studies reconfirmed the importance of Leske's family needs categories [43][44][45][46][47][48][49].Therefore, the importance of designing an ICU to meet these categories of needs has been established.
Other related lines of inquiry showed that needs are viewed differently by family members and health care professionals [38,40,50].Thus, nurses often provide routine responses and generalized interventions to family members and waste energy attempting to respond to nonexistent needs.Norris and Grove [40] found that nurses tended to underestimate the needs of family members.Lynn-McHale and Bellinger [38] found that among the six categories based on the needs statements of Molter's instrument, personal support systems, visitation, information, psychological aspects significant to the family, environmental factors, and institutional support systems, it was only the last category on which nurses and family members agreed in their estimates of satisfaction.These findings suggest that caregivers and family members have different priorities concerning ICUs.While ICUs are often designed to meet the priorities of caregivers, it is important to conduct a gap analysis between caregivers' and families' priorities in designing ICUs.
In addition to many studies on needs and satisfaction levels of family members of critically ill patients, both quantitative and qualitative studies on the experience of family members-their emotional distress, and affective and behavioral responses-have also been reported [20,21,29,47,[51][52][53][54][55][56][57][58][59].Kleiber and colleagues [47] asked family members in different ICUs in a large tertiary care hospital to keep daily log of their experience and feelings.Thematic analysis of the log revealed a broad range of powerful emotions, including sadness, depression, hate, anger, exhaustion, and fatigue.Appreciation for the support offered by others was expressed frequently.A commonly identified supportive behavior was providing information about the patient's condition.Quiet presence was apparently viewed positively by many family members.Communication, which was considered different from providing information, was described as sharing of thoughts and feelings through talking to and listening to friends and relatives.Other supportive behaviors were assistance and comfort.The study concluded that based on families' emotional responses, it is necessary to support the families throughout the ICU stay, and indicates a need for flexible family spaces designed to promote comfort, social interaction, and privacy.

Information
(the need for information that is consistent and realistic)

Comfort
(the need for personal comfort that facilitate remaining near the ill family member)

Needs in ICUs Assurance
(the need to hope for a desired outcome)

Support
(the need for resources, support systems, and supportive structures during and after the critical illness)

Proximity
(the need for personal contact and to be physically and emotionally near the critically ill patient)
In a more recent qualitative study directly addressing the environment, Kutash and Northrop [20] described family experiences of waiting rooms in adult ICUs using semistructured interviews.Six categories of themes emerged from data analysis revealing both structural and subjective aspects of waiting: 1.
Close proximity referred to the importance of a close physical distance to patients, which was central to easing the waiting period.Regarding close proximity, Bournes and Mitchell [21] found that family members talked about "not wanting to go too far away -just in case", and "being there to see that he is still breathing".

2.
Caring staff captured the comfort family members felt when staff showed caring behaviors towards loved ones.However, family members did not focus on caring behaviors directed towards them.

3.
Need for a comfortable environment represented the impact of the design of the waiting room on family well-being.The study found that family's perceptions of the waiting room were mostly negative.Some described the room/space as cold, dirty, a small space and "a place to go, not to stay".Others suggested that the waiting room needed to be a little bit more human friendly.Yet others described the furniture as uncomfortable to sit in and too close together.They talked about having water in the cooler and having enough clean blankets and pillows.

4.
Emotional support referred to the fact that family members found the waiting room to be a place where they could obtain emotional support.It was described as a place where "one family consoles another family" and "a place where you can be with people in similar situations".Rodgers [42], who observed behaviors and interactions of individuals who shared an ICU waiting room, described it as a community of "former strangers who had become united by some common experience".

5.
Rollercoaster of emotions captured the range of emotions experienced by family members.

6.
Information referred to the importance of receiving information about their loved ones.The comments by participants in this study suggested that the waiting room enhances the ability of family members to receive information about their loved ones by face-to-face communication.
These findings indicate a need to design waiting spaces to promote a comfortable and calming environment, and to give families easy access to and sufficient visibility of patients.They also indicate a need to design waiting spaces to enhance communication between the healthcare team and families, and to facilitate better access to information.
In an interesting study, Burr [58] used both CCFNI and interviews to provide a contextual representation of family needs in ICUs.Her results indicated at least two major needs that are not included in CCFNI: the need of family members to provide reassurance and support to the patient, and their need to protect patient and family.The family members' need to support and reassure the patient was a common response to the feelings of helplessness.The need to protect was revealed through concerns to prevent or minimize anything that would upset or worry the patient.Information was withheld if it was considered disturbing to the patient.Other visitors were screened for the same reason.The need was also related to preserving the patient's dignity and privacy.These findings indicate a need for designing an ICU to include space to sit vigil and to promote patient privacy and dignity.
In addition to the quantitative studies of family needs and the qualitative thematic studies of family's experience, several quantitative studies on family members' behavioral responses related to ICU experience are also reported in the literature.In one quantitative study, Halm and colleagues [49] found that family members slept less, had poorer sleep, took fewer naps, and slept in the waiting room about one third of the time.They changed eating behaviors, and ate more snacks and "junk" food to limit the amount of time they were away from the ICU.They spent less time watching television and more time talking, visiting the patient, and waiting during the critical illness.The majority of family members reported feeling "very tired".Finally, they all had a very high level of stress at the time of the critical care admission.Stress began to plateau on Day 6 and then dropped considerably by Day 28.In other words, over time, most family members successfully adapted to the stress associated with critical care hospitalization, a finding that was confirmed by Auerbach and colleagues [59].These behavioral responses indicate that family spaces in ICUs need to be quiet and calming to promote rest and sleep.They also need to be conducive to social interaction.Probably, it would be best for families to get food within the unit so that they can always be close to patients.Finally, the environment needs to therapeutic and free of stressors of any form.
In summary, studies on families in ICUs suggest that their needs, experience, and affective responses are important from the viewpoint of patient-/family-centered care.These studies also indicate several ICU design issues concerning these needs, experience, and affective responses.A discussion of these design issues within the framework of the healing environment of care is in order.

THE HEALING ENVIRONMENT OF CARE AS A MODEL FOR FAMILY INTEGRATION
In a study conducted by the Picker Institute [60], patients and families disclosed or related that they considered healthcare environments to be "healing" when care was attentive to mind, body, and spirit, when they felt they had a relationship with their healer, and when they were actively involved in the decision-making process.Fundamentally, a deliberate caring relationship between a caregiver and the patient and patient's family is the core of the healing environment.In general, a healing environment can be viewed as having two components-the intangible culture of care and the tangible healing design.

The healing culture of care
A healing culture of care is that in which there is an obvious regard for the dignity of human beings, and where relationships between care seekers and caregivers are built on mutual respect and a shared commitment to healing.In such a culture, caregivers understand that each encounter with patients and their families is an opportunity to convey care and respect-from gathering and giving information at the time of admission, to responding to a request, to transporting patients, to stopping to offer directions in the hallway, or to simply acknowledging someone who is in need.This means that every member of the hospital staff, regardless of their job description, has a role to play in a healing culture.
Many hospitals and ICUs have proposed models/programs for improving their culture of care.They focus primarily on behavioral and organizational changes including changes in (a) visitation policies (b) decision-making processes regarding patient care, (c) medical round practices, (d) cultural, religious and spiritual support, and (e) in staff interaction with family members.Without an environment to support family presence, these mandates could increase staff stress.
Dowling and her colleagues [61] reported that family satisfaction ratings were impacted more favorably by the family's perception of their feeling safe and secure in the hospital environment than by the family's perception of the culture of communication and care in ICUs.The same study also reported environmental amenities such as "a private place in the hospital to sleep and rest while waiting" and information related to the environment, such as "information on local places to stay or eat" having a positive impact on family satisfaction ratings [61].Therefore, in addition to the culture of care it is necessary to consider the ED dimensions of ICUs in relation to family perception, experience, and behavioral responses if the goal is to improve family integration with patient care in ICUs.

The concept of healing design
Unlike the mostly intangible healing culture, a tangible healing design makes healing intentions evident in the way it attends to the entire experience of its users.The healing design needs to be comforting and pleasant to all human senses.For example, an overemphasis on visual needs may undermine other sensual needs of users.However, it is not enough for a healing design to be pleasant to human senses only.It must also be uplifting, inspirational, and even spiritual.Additionally, a healing design needs to be sensitive to the socio-cultural needs of its users.It recognizes that what works well for one may not work well for another.Regarding healthcare settings, the healing design must not contradict the culture of care.For example, an unrestricted visiting policy in an ICU may become ineffective or counterproductive if there is not enough family space in the unit or patient room; in a shared decision-making culture, it may be difficult to organize meetings between staff and family as needed if meeting spaces are not available.In sum, the healing design involves the physiological, psychological, as well as socio-cultural wellbeing of its users.
So far, the role of the healing design in family integration models/programs has remained marginal.This is in part due to a hospital organization that is economically challenged, and in part due to the ineffective role of architects/designers in raising ED awareness and in creating healing environments where ED provides significant restorative benefits.Most hospital administrators emphasize processes related to efficiency, often causing hospitals to become noisy, cluttered, unpleasant environments with little regard for the potentially detrimental effects of these environments on the physical and/or psychological well-being of patients, families, and staff.Only recently, do we find some hospitals beginning to invest in ED for improving the experience of patients and their families.The reasons for this change can be found in the environmental research design literature.

ENVIRONMENTAL DESIGN FOR PROMOTING FAMILY INTEGRATION IN ICUS 5.1. Environmental design recommendations for family waiting areas/spaces: literature review
Though studies on the effects of ED on family needs, experience, and behavioral responses in healthcare settings in general and in ICUs in particular are rare, the effects of ED on patients and staff are somewhat well studied.As more ICUs seek to integrate families with patient care, families are likely to spend more time with their loved ones in ICUs.Consequently, families may be affected by some of the same ED features affecting patients and staff in ICUs, though not always to the same extent.Many excellent review articles report the effects of these environmental features on patient, family/visitor, and staff outcomes at some length [19][20][21][22][23][24][25][26].These review articles look at studies involving almost every environmental design feature including noise, music, lighting, aroma, air quality, and view of and access to nature.They also look at studies involving different behavioral, social, psychosocial and spiritual factors.
Most comprehensive among the recent review articles are the two by Ulrich and his colleagues [84][85].Ulrich et al. [84] review more than 600 peer-reviewed articles published since 1968 on the effects of physical environment on healthcare outcomes.The other review [85] includes those studies published between 2004 and 2008, and those that report findings in areas of healthcare environment not included in their previous article.Rashid & Zimring [78] review about 250 articles reporting the effects of indoor environment in healthcare and office settings.This review article is relevant to this study because environmental effects on healthy individuals in office settings may be somewhat similar to that on patient family members in healthcare settings.Other reviews on healing design can be found in [19,23,24,25,26,80,89].
Table 1 presents a summary of the environmental design research findings for different important environmental issues, and Table 2 presents the same for behavioral, social, and psychosocial issues.The tables include only the findings that appear relevant to families in ICUs.They also contain ED recommendations in relation to the findings.The recommendations are quite generic in nature, and therefore can be applied to any hospital spaces to be used by patient families during the course of their stay in the hospital.Specific ED recommendations for family areas, that are not included in the tables, are discussed below.

Environmental design recommendations for family waiting areas/spaces: the author's perspective
The location of family waiting spaces in ICUs is very important.It defines visual and physical access of families to patients in ICUs.It also signals the degree to which families are integrated with patient care [27].Family spaces can be provided outside the unit, inside the unit, within the patient room, and/or at more than one of these locations.Family spaces located outside the unit may suggest that families are not integrated with patient care in the unit.On the other hand, family spaces provided within the patient room may indicate that families are well integrated with patient care.Family spaces provided within the unit but not in the patient room may indicate that the role of the Attention should be given to making • The ratio of hours of light versus hours of natural light available in all family darkness may influence circadian spaces in the unit.rhythms of humans.
If the family space is within the patient • Higher color temperature or higher light room, make sure that the intensity of levels increase alertness.
natural light is comfortable to patients.

• Any affective response to lighting are often
The use of slightly tinted or reflective determined by traumatic experiences or glass can effectively reduce glare and by such factors as education, and heat production from natural sunlight.social and cultural values.
Vertical blinds and other window • Low-level lighting seems to encourage treatments can be used for adjusting longer conversations.light intensity as desired by the patient.• People feel uncomfortable if they are • Consider the following regarding artificial unable to control lighting levels to light in family spaces: suit their own requirements.
It is important to consider multiple • Some negative effects of fluorescent light options for lighting that can be with magnetic ballasts can be solved controlled when desired.using digital ballasts.
Where natural light is not an option • Full-spectrum fluorescent lighting has (older ICUs), consider using fullsome of the same emotional and spectrum fluorescent lighting.physiological effects as natural sunlight.
A dynamic lighting solution that allows the color and temperature levels (Continued ) Night lighting must also be considered since the patient will be frequently checked and observed by the family or the clinical staff.While providing ambient light, glare needs to be prevented from interfering with monitoring screens.Avoid heat gain from ambient light sources on sensitive oximetry and ventilator alarm systems.In sum, when selecting lighting options in critical care units, a variety of characteristics must be considered: technical lighting needs, soft lighting for relaxing, and night lighting, as well as the location, intensity, and controllability of the lighting.Any lighting solution that lacks variability and controllability may fail to meet individual demands in the stressful environment of ICUs.Also, light switches need to be placed ergonomically and in a location accessible by the family without interfering with equipment.

Findings ED Recommendations
• Uncontrollable situations or conditions the type and volume of music, and the usually are aversive and stressful.
timing and content of meals will • Having a sense of control with respect experience less stress and will to a potential stressor help reduce the likely be more satisfied.negative effects of the stressor.
• Giving patients and their families an • In hospitals and ICUs, patient families opportunity to personalize their are under stress because they are unable to environments may also give them a control noise; they have difficulties sense of control and familiarity.finding their ways; they have no personal • Consider flexible furniture arrangements, control over lighting and temperature; and or allow families to change furniture they frequently have no privacy.layout to meet their needs.Seating arrangements that cannot be changed or chairs that cannot be moved may cause frustration among families.
Privacy [112][113] • Privacy can be interpreted as the need to • It is necessary to express clearly in design control or regulate access to the self.
the fact that privacy varies along a It is an important psychosocial need continuum ranging from the public to for humans.the intimate.A good ED allows a • Privacy is often an important determinant gradual transition between these of individual satisfaction.
extremes.Consider the following • Despite the growing importance of privacy in this regard: in healthcare settings, existing research A hospital lobby, the most public space in this area is sparse. of all hospital spaces, should be an  Arranging seating side-by-side along supply rooms.They may also visit patient room walls inhibits social interaction.rooms more often, creating opportunities Private and peaceful spaces may help for additional interactions, monitoring, improve communication.and care.
People may interact longer in dim • Furniture arrangements affect group lighting conditions than in bright behaviors including social interaction.lighting conditions.

Findings ED Recommendations
Softer flooring materials in patient rooms may make family members stay longer.Wayfinding [62,64,[128][129][130][131][132][133][134][135] • As hospitals become more complex, poor • Wayfinding problems cannot be tackled wayfinding systems can be extremely costly piecemeal.The ED of a well-integrated in terms of both patient and family wayfinding system should include satisfaction and hard dollars.
external building cues, functional • People tend to move along routes that are information, and an intelligible more accessible from a greater number building layout. of spaces; this emphasizes the importance • Wayfinding must be made a part of the of the overall structure of an environment building design process.Every time the from the viewpoint of wayfinding.
building is renovated or changed, or • You-are-here maps, directories, and departments change their locations or signage are important wayfinding aids.
functions, wayfinding needs to be • When you-are-here maps are aligned in evaluated for appropriateness.directions other than the forward position, • It is important to identify routes that are, people take much longer to find their on average, more accessible from destination and their efforts become a greater number of spaces in the layout significantly less accurate.
when placing important facilities and key • People with necessary functional points such as the entrance.information upon reaching hospitals are • Wayfinding must be considered keeping in more self-reliant and make fewer demands mind that families with critically ill on staff.In contrast, people without the patients in ICUs often develop symptoms information rate the hospital less of anxiety, depression, and posttraumatic favorably and have elevated heart rates.stress syndrome.As a result, they are • People in hospitals who have access to more susceptible to information overload, more signs along the way are faster, less able to process information provided less hesitant, ask for directions fewer by the environment, and are more times, and report lower levels of stress.
dependent on the assistance of others.• In many complex facilities, first time • Cafeterias or food courts needs to be easily visitors must spend extra time and energy accessible from family waiting areas, to find their way around a poorly designed and appropriate directional maps and building.
signs should be provided.• Patient families may also be the first-time visitors to the hospital.Consider the following in this regard: Signs should be in areas with sufficient lighting.Use such artifacts as sculptures, photographs, or paintings as important orientation cues.Atriums and galleries, instead of a long corridor, are effective wayfinding tools because of their distinctive design.A view of the sky, the outdoor, and/or the ground may help maintain orientation for visitors not yet familiar with the environment.Unique floor tiles, room carpet of a different color from the hallway, private patient mailboxes at the entrance of a room, and unique patient room entrances can help family members locate a specific room along a corridor of rooms.family in patient care is in a state of flux in the unit.Of course, such a reading of patient/family centered care based on spatial layout may at times be wrong.Some units may still not allow families to play an active role in patient care even with families present in the area designated for them in the patient room.
For families to feel safe and assured, they need access to both patients and their caregivers.Families are in distress when access is denied or restricted either to patients or to caregivers.Regardless of locations, family spaces should provide easy visual and/or physical access to the patient rooms because families would often need to see the patient.Families should also have easy access to caregivers when needed.It is generally accepted that, for patient safety it is best for families to enter the unit through a separate entry other than the one/s used by service and clinical staff.Designers must make sure that in designing such a system of entrances they do not make interfaces among families and caregivers difficult.Families must know when caregivers are available in the unit to answer their questions.If the ICU design restricts such interfaces, families may simply gather themselves at places where they are likely to find caregivers.
In laying out the family waiting area, the metaphor of home may be apt.Like home, waiting areas may be broken down into zones with varying degrees of privacy and control.Waiting areas should be large enough to accommodate all family members comfortably.Waiting areas can be sectioned to provide more intimate and quieter resting spaces and relatively busy and noisy activity spaces.Families with children should be given spaces separate from a "quite zone" for adults only.A play area for children within the direct visual reach of the adult family members should be considered in the area designated for families with children.Each section can be separated by solid partitions, dividers, glass walls, or planters depending on the need of these spaces.Each section should contain comfortable chairs and/or sofas for the family.Both resting and activity spaces should include private spaces or booths for telephone conversations.Additionally, activity spaces should not only include computers with internet access, but also allow families to access these computers to keep themselves up-to-date with patient status as well as with the outside world.Activity spaces should also include study carrels with health care information that families can access during their waiting periods.It is desirable to create a media room to separate the television from the rest of the waiting area, ensuring that families who wish to have quiet and solitude while waiting are not disturbed by television noise.Some hospitals are providing family sleep rooms with private bathrooms, kitchenettes and laundry in their waiting areas for family members who must stay at the hospital for an extended period of time.Such accommodations are helpful for family members who live a significant distance away from the hospital or who wish to stay with the patient.
Attention must be paid to furnishings in the family areas.Furnishings should be durable, comfortable, and cheerful.Furnishings should include comfortable seating for the visiting family and the option of a wall-mounted fold-down bed or foldout chairbed, particularly in any family space within the patient room.When selecting furniture, designers should consider such epidemiological concerns as the rising incidence of obesity.Any unnecessary sources of visual stimulation should be minimized.Wall furnishings should not be of bold patterns or colors that can be misperceived as threatening objects (such as bugs, animals, figures, etc.) by patients and/or their families.Wall coverings and colors should have a soothing, relaxing effect on the ICU population in general.
If possible, each patient room should include a well-defined family area.In a family space within the patient room, families are able to be present for shift change report, teaching sessions, care-planning discussions, and for participating in daily medical rounds.A family space within patient room provides families a more comfortable environment for activities.In this regard, consideration needs to be given to reducing environmental factors that disturb family members who remain in the patient room.Quiet, dimly lit areas for naps and sleeping can be provided along with comfortable furniture.Being able to sleep in the patient room also provides social support and reassurance for both the patient and family members.

BARRIERS TO IMPLEMENTING HEALING DESIGN IN ICUS
While much of the thrust for healing design in ICU and healthcare architecture comes from ED research literature, a lack of research in many areas concerning patients and families has been a significant barrier to healing design.For example, regarding human senses, studies on the role of tactile qualities of architecture in the process of healing has not been reported in the ED research literature.There is enough evidence available on noise/sound, light, and smell/aroma to help guide the process of healing design, but there is almost none available on tactility.This is an important limitation concerning healing design.It is suggested in the literature that touch is "the mother of all senses" [141].In fact, haptic experience may be particularly relevant for families in ICUs, because humans seem to prefer touch in the most intense moments of their lives [142].
Regarding human experience, there is also a lack of evidence on the effects of design on memory, spirituality, and other deeper qualities of human nature in healthcare settings.Humans seek refuge in memory and spirituality when faced with a lifethreatening event.It is known that nature can provide spirituality and evoke memories (Table 2).However, no systematic research has yet been undertaken to study how architectural features of the ICU environment might evoke spirituality and/or memories to enhance the healing process.This is despite the fact that architecture has always been concerned with symbolism, spirituality, and memory.
The paradigm of ED research practice itself has stymied research in many areas concerning healing design in ICUs.ED researchers in general conceive the environment as a collection of attributes.For them, ED generally includes both ambient environmental features and physical design features.Ambient environmental features include noise, music, lighting (both natural and artificial), ambient temperature, and air quality, whereas physical design features include the layout of spaces, functions, furniture, fixtures and equipment, finish/surface materials, color, artwork, natural views, and environmental graphics.In numerous reported studies, researchers focus on some particular elements of the environment while controlling for the others-either statistically or through research design.There is a lack of studies reporting the interacting effects of physiological, psychological, and socio-cultural aspects of an environment on health outcomes.In the absence of any such evidence, the synthesis of research evidence in design becomes arbitrary.
Another issue that has stymied research in healing design is that hospitals and researchers alike generally have been interested in a disease-or patient-focused care emphasizing more on the clinical dimensions of ED in healthcare, particularly in ICU.Consequently, it has been difficult to translate the results of family-centered studies into health-care improvements programs within ICU.Additionally, the bulk of the studies in the ED area pertain to patient (not family) outcomes, even though in many cases these outcomes may be intertwined.Thus, further studies are needed to validate that research findings related to ED for patients are generalizable to family outcomes.Yet another important issue is that hospital administrators need to be able to prioritize those dimensions of healthcare that predict hospital outcomes better.Traditionally, empirical studies on family integration have been less successful in this regard.
Expenses are also a barrier to the healing design.It has been difficult to justify any amount of investment on the healing design in terms of hospital earnings.As a result, designers have been unwilling to apply healing design strategies.For example, gardens are a useful component of the healing design.They are probably most effective in congested urban conditions, where families often have no access to nature.However, in big cities, hospitals are built on expensive real estate.It is not easy to convince the administrators that gardens can be as cost effective as, for example, ten additional patient rooms or one additional diagnostic lab in terms of hospital earnings.It may take some time and effort before these administrators realize that creating a healing environment is not contradictory to focusing on containing cost and improving care efficiency.Studies have shown that healthcare designs based on good research evidence are solid economic investments for improving health and organizational outcomes [143][144][145].In other words, a healing environment may help further the performance of an organization that values compassionate caring involving patients and their families.
Concerning environmental technology, some healing design recommendations are expensive while the others are not.For example, lighting systems that simulate natural light or that work with natural light, or multiple lighting systems that meet different visual, emotional and biological needs of patient families can be expensive and difficult to maintain.Similarly, ICU design that allows patient families to control lighting, music, temperature, air velocity, and/or privacy can be expensive because of the degree of controllability and flexibility required to meet the peculiar needs of every patient family.In contrast, signs to help wayfinding, HEPA filters to improve air quality, aroma to conceal unpleasant smells, or soothing color to promote calm and rest are relatively inexpensive design interventions.
More and better information related to environmental technology and cost effectiveness as related to healing outcomes is needed.Many hospitals today are unable to find creative ways to engineer the current structure for healing without huge costs.There is not enough information available to guide the selection of furniture, lighting sources and placement, surface materials, and noise abatement strategies for healing design in ICUs.This type of structural, engineering information would be extremely helpful for the engineers and architects in designing a healing environment.
Finally, a healing design in ICUs often requires cultural changes that are difficult to make.For example, recommendations are made to include family spaces within ICUs and patient rooms to improve families' access to patients and care providers.However, it can be difficult for some providers to have families around them when they serve patients.Interventional programs to change the culture of practice may be helpful in this regard.However, such programs require longer commitments, thus can become expensive.

CONCLUSION
A "healing environment of care" model for patient family in ICUs is proposed.By integrating environmental design as an important dimension, the model aims at overcoming the limitations of those family integration models that focus only on changing the culture of care.It is argued that without appropriate environmental design to support family presence and integration, any mandate to change the culture of care can increase staff stress, and hence may soon become counter-productive.It is also argued that supporting family integration through healing design involves an understanding of the physiological, psychological, as well as socio-cultural wellbeing of patient families gained through studies of their needs, experience, and behavioral responses in ICUs.Based on the existing ED research evidence, generic design recommendations are made to promote healing design in ICUs in relation to various environmental, behavioral, social, and psychosocial issues.Specific design recommendations are also made to promote healing design for family spaces in ICUs.Due to a lack of ED research on ICUs, these specific recommendations reflect mostly the author's point of view.Together, these ED recommendations may help transform the aversive, technology heavy ICU environment into a healing environment for patient families.